when to reduce apixaban dosage?

[GrannyE]

I am being monitored for kidney deterioration on a regular basis because of taking 5mg x 2 daily Apixaban. My latest blood test showed they are deteriorating slowly and am now in stage 2. I am nearly 80, and under 7stone 9. I feel as if I am between a rock and a hard place. I really really don’t want a stroke but I do want healthy kidneys. Am speaking to a GP on Friday. Any advice please?

[JOY2THEWORLD49]

Hi

There are other anti-co.agulants. I'm on PRADAXA.

Are you persistence or have episodes?

If you experience the latter you could take the anti-co.... as PIP.

cheri JOY. 73. (NZ)

[GrannyE in reply to JOY2THEWORLD49]

Don’t know about Pradaxa. I thought that Apixaban was the best but I am being monitored. My A/Fib comes and goes now but never know when it might be triggered so need to be on anticoags all the time. If I had say a year of no heart problems would consider as a PIP.

Thanks for replying

[10gingercats in reply to GrannyE]

I was told I needed to drop my Apixaban from 5mgx twice daily to 2.5 xtwice daily at 80.....organised by GP a few years ago. I did not have any renal issues then or now as far as i know. My bloods are checked about twice yearly .

[GrannyE in reply to 10gingercats]

Obviously you have not had a stroke and the 2.5mg x2 seems to suit you. I will reach the dreaded 80 in Jan so not far off it. Good to know. Thanks

[JOY2THEWORLD49 in reply to GrannyE]

Hi

Like Pradaxa Drs may prescribe 150mg or 110mg twice a day.

But

contra is the fact that you have a heart condition so I would tell Dr lower the dose.

I was in fact prescribed 110mg at Whangarei after the stroke. But a transfer to Kaitaia more north but closer to home, Kaitaia changed it to 150mg x 2 day.

I was livered when I put the two discharge papers together.

With squeaky clean Carotid Arteries the endoecrinologist at 70 years put

me on 110mg.

cheri JOY. 73. (NZ)

[Ducky2003 in reply to GrannyE]

They would never be suitable as a pip as far as Im aware for the reasons in my reply to Joy.

You may wish to discuss halving your dose?

[JOY2THEWORLD49 in reply to Ducky2003]

Hi

The latest is to keep anti-coagulants to minimum.

It leads to folks who have 1 episode a month or year to take it when

they get AF. It seems to some folks they know its going to happen.

After my stroke with AF the hospital tried to give me aspirin. I failed because I couldn't swallow. I had a drip so it was put in there.

Perhaps an aspirin immediately and I am aware that aspirin works differently than anti-coagulant.

cheers JOY 73 (NZ)

[Ducky2003 in reply to JOY2THEWORLD49]

Drs are reluctant to prescribe aspirin over here, as that can come with a lot of side effects as well. Whenever I've had it, years ago as a painkiller, it upset my stomach.

I still say, whatever anticoagulant you take, pip will not be effective, as the clot could already have formed by the time you realise you need it and the tablets will not dissolve clots once they are formed. You would need an antithrombotic at that point and hopefully, you'd get to the hospital in time to have one, before a clot does its damage.

Depends on how much you want to risk so, obviously up to the individual 🤷‍♀️.

[Ablation7 in reply to Ducky2003]

this makes sense; I’d be very hesitant to use my xarelto as pip.

[Ducky2003 in reply to Ablation7]

Too risky in my humble opinion.

[whats in reply to Ducky2003]

That is not true. Clots form and often stay where they are (frequently the left atrial appendage, which has low blood flow during a-fib), then are released, I don't know why they are released just that they can persist harmlessly. This is what I read in research journals. Also, ACs do dissolve existing clots, eg in a study of heart attack patients who were given ACs, they were as effective as warfarin at dissolving clots. Sorry I can't find links to the articles.

[Ducky2003 in reply to whats]

Something "often stay where they are" is not an acceptable risk to me but obviously, that is individual choice.

Apixaban does not dissolve existing blood clots........ information readily available on the web.

Also, in the UK, you will not be given an elective DCCV if you have missed just a single dose of your anticoagulant within 3 weeks.

If you need an emergency DCCV, you will have to have a awful TOE procedure first if you are not taking anticoagulants.

As I say, individual choice and having seen the effects of a stroke, I'd rather reduce the risk of having one.😊.

[whats in reply to Ducky2003]

pubmed.ncbi.nlm.nih.gov/273... In 2015:

"While novel oral anticoagulants (NOACs) have been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation (AF), they are not indicated for resolution of intracardiac thrombus. The case of a 60-year-old woman with left ventricular (LV) thrombus secondary to hypertrophic cardiomyopathy and AF is described in the present report. Indications for oral anticoagulation were AF and LV thrombus. Thrombus was dissolved after 1 month of apixaban treatment. To the best of our knowledge, this is the first report that describes the resolution of LV thrombus with apixaban treatment in a patient with hypertrophic cardiomyopathy. " That was in 2015/

If you search the pubmed.ncbi.nim.gov website for "apixiban dissolves clots" numerous research articles come up with examples of how it does dissolve clots. I don't know if it's FDA approved as a thrombolytic (clot dissolving) agent, I don't know what websites your talking about.

Please don't be defensive, its an important thing to understand. In the situation we're considering, where you are using apixaban as a pill in the pocket, which a lot of doctors approve for "particular patients", so they say. But I don't know how infrequent afib needs to be for that use. And for people who haven't had a-fib for a year, could they still have clots lurking? I don't know. I'm just learning about it all these last few months and have a lot of questions. Articles I've read suggest that EPs look for clots before an ablation.

I just know apixaban is super-expensive in the U.S. and I just ordered a 3 month supply for $574 and its going up to $250 a month next year. Anybody in U.S have a better Part D drug plan? I'm planning to use it as directed for a month or so to dissolve any clots I may have, then use it as a pill in the pocket.

[GrannyE in reply to whats]

we are so lucky in England to get it for free on the good old nhs. Thx for replying

[Ducky2003 in reply to whats]

Im not being defensive in the slightest. I will repeat, its the individuals choice.

In the UK, anyone who pays for prescriptions pays a flat fee of about £9.50 so that would be for a month supply or 2 or 3 if your GP is nice enough to sign that off. So, I can understand your wanting to look at a way of not taking them at the price you pay.

Ultimately, I am happy to follow my cardiology team's advice. Currently, thats because Im waiting for procedures to try to resolve the AF but if they recommended that I continue with the anticoagulant afterwards, if they provide me with adequate reasons why, I will listen to what they say.

Your decision, my decision, as long as we are happy with our own decisions, then all's good.

[GrannyE in reply to whats]

it is reassuring to hear they dissolve clots. I thought that when on apixaban the clots did not form in the first place

[Ducky2003 in reply to GrannyE]

UK advice is that it does not dissolve pre existing clots so do your research before going thinking of going against your own doctors advice. Just be careful.

[Alwayzlrning in reply to GrannyE]

while in the hospital 4 years they found I had a clot in my arm after pain and swelling from the IV. They had just started me on Eliquis Apixaban 5 mg 2/daily for AF and told me that it would not dissolve the clot. Also, clots can still form and cause stroke even while on Apixaban, it’s like a protection with insurance but only up to 60% Several doctors over the years have told me that a dose must never be missed and could not be used as pill in pocket since it could form a clot and cause a stroke before you’re aware of the clot being there. yeah, it’s expensive, but like Ducky said, it’s up to the individual how much risk they’re willing to take.

[JOY2THEWORLD49 in reply to Ducky2003]

Hi

Thanx.

I was given aspirin at arrival at hospital after stroke at 2a.m

I awoke with a very sore head. I trodded to toilet. Too tired so not looking in the mirror I went back to bed.

I awoke 5.30, didnt make the toilet, had a shower, looked in the mirror and

rung our 111 emergency.

Aspirin was administered in emergency, I had a left frontal lobe embolic stroke.

Later I was put on PRADAXA. I chose PRDAXA as twice a day. 110mg for older, heart probematic folks.

No drugs except Vit B12 nugget under tongue 2 days week. It is off production at moment. SOLGAR gold top brand. Trusted and proven with my Dr from 2010.

Choice and manage my health is important to me.

JOY. 73 (NZ)

[Ducky2003 in reply to JOY2THEWORLD49]

You couldnt use an anticoagulant as a pip they do not react that quickly. Also,, if you didnt realise you were in AF immediately, the clot could already be on its way around your system before you know it.

[CDreamer]

I believe that apart from regular monitoring you may not be advised to reduce the dose, unlike some of the other anticoagulants but good idea to ask about monitoring - ie:- regular blood/urine tests so ask about that. Apixaban is considered the least symptomatic and needs no adjustment of dose. I wouldn’t dream of asking for another anticoagulant as having experience of a few, it is the most benign in my view.

ncbi.nlm.nih.gov/pmc/articl...

Conclusions - Although there is a need for cardiorenal consensus regarding anticoagulation in CKD, adequate selection of the anticoagulant type and careful monitoring are some extremely useful indications for overcoming management challenges.

In other words - maybe ask your GP to write and get a view from both Renal and Cardio?

Sometimes it is a choice between the greatest and most immediate risk factors. Kidney function declines with age anyway and stage 2 means there is some damage but your kidney’s are still functioning.

[GrannyE in reply to CDreamer]

Thanks for that.

I agree that Apixaban is the best anticoagulant. I am being monitored regularly for kidney function because of the Apixaban. I am slightly terrified of kidney problems because my poor husband is in band 5 and has to be extremely careful. Dialysis sounds dreadful and he is being threatened with that in the not too distant future. My A/Fib now seems to come whenever my body is under stress, i.e. vaccinations, fighting some infection or other, mental stress etc I get supra ventricular ectopy. Last A/Fib Aug 17th.

[CDreamer in reply to GrannyE]

Stress is IMHO the biggest antagonist for AF so management of worry is important and there are lots of strategies for managing - best - breath exercises.

[GrannyE in reply to CDreamer]

Yup you are right. I do breathing using abdomen. Essential oil of lavender. Try to think positive beautiful thoughts. Count blessings. Put something light hearted on TV. Try to lift corners of mouth etc.

[Ablation7 in reply to GrannyE]

I love that you lift the corners of your mouth”. It does make you feel good. I’m all about being happy! 😊

[GrannyE in reply to Ablation7]

It is supposed to do so. If you really feel you cannot smile i have been told that putting a pencil horizontally between teeth does it for you.

[GrannyE in reply to Ablation7]

Put it this way. It cannot do any harm and might conceivably do some good

[Nerja2012 in reply to GrannyE]

My thoughts exactly. Im female 78 soon , and weigh 8st 4lb. Paf , episodes average 2 a year ,no comorbiditys. Chads score 3 for no other reason than age and gender. I only take 2.5mg Apixaban which is half dose, my consultant was ok with that but did advice 5mg.

[CDreamer]

👍

[Cat04]

Under NICE guidelines your gp may consider a lower dose of Apixaban to be more suitable if you are a) over 80, b) under 9½ stone, c) have kidney problems.

I am (lower end) stage 2 kidney disease & weigh under 9 stone but not quite as senior as you, but still take 5mg twice daily. I'm sure your gp can either adjust your dose if they feel necessary or reassure you to continue at the usual dose.

[Pitterpat]

I'm 67 and on apixaban 5mg twice a day. I have been told twice - by clinic and GP pharmacist - if my weight falls below 60kg to contact them and the dose would most likely be reduced.

[GrannyE in reply to Pitterpat]

That’s interesting. I have always maintained that giving the same dose to a 17stone man as an under 8stone woman is probably not right.

[RoyMacDonald]

I weigh 50kg and 9 months ago the consultant told me to stay on 5mg twice a day (for full protection). I'm78.

All the best.

Roy

[GrannyE in reply to RoyMacDonald]

Thanks

[Daisaku]

Get the watchman device.

[LaceyLady in reply to Daisaku]

easier said than done in the UK

[Suebo2]

hi, your quite right to ask the question, and it’s sad that doctors don’t have time to explain rationale.

Put simply:-

Rationale for reducing the dose is that your kidneys excrete the medication to a certain degree

If your kidneys are not working properly then there is a small risk that you could be taking too much of the anticoagulant and potentially increase your bleeding risk.

The decision for reduction is based on a measure of your kidney function - called créatine clearance, and this is worked out by measuring your creatinine in your blood and weight and then using a formula called Cockcroft Gault.

Please don’t worry, it’s good that they have thought about dose reduction.

Sue

[ozziebob in reply to Suebo2]

Suebo2,

I've just read your bio mentioning anticoagulation work experience. Can I please ask something I need help with?

I am still waiting for the appt recommended for me with my local Anticoagulation Team.

However in late 2016 I suffered chronic bilateral subdural haematomas. Cause unknown. Naturally I live with the thought that such an event could recur at any time going forward. So my first thoughts are that I would prefer not to take anticoagulation medication, and take the risk (knowing also that historical stroke risk %s were based on patients with comorbidities, not lone AF sufferers like me).

Could you comment on how my medical history might affect the thoughts of an Anticoagulation Team. It has been suggested to me that I might well be unsuitable for anticoagulation.

All thoughts welcome. Of course I realise you don't have my complete medical record, but it's the previous haematomas that seem most relevant to me in this decision making, and your general comments would be extremely helpful.

Thanks

ozziebob (aka bob)

[Suebo2 in reply to ozziebob]

dear Bob, thank you for asking the question , and I can understand your concerns.

A decision to Anticoagulate or not should be taken by a medic with good understanding of all your risks.

What is the risk of more haemorrhagic episodes ?

What is your personal risk of stroke? - taking into account all your medical issues.

I am not able to give you direct advice, but merely to help support you with making the decision.

If Anticoagulation not a good idea there are other things that you can do to reduce risk of stroke. Depending on your situation there is a ‘left atrial appendage occlusion device - Watchman- which effectively blocks out the appendage so that it does NOT fill with clot which could cause a stroke if forced out when the heart decides to contract effectively.

My best advice is to make an appointment with a haematologist and go armed with your research and ask advice.

I wish you all the best.

[GrannyE in reply to Suebo2]

Thank you Sue. Interesting

[Karendeena]

my mum who is 94 is on 2.5,mg twice daily

[GrannyE]

Spoke to doc last Friday. He said that almost everyone around 80 was in stage 2 kidney and I should not worry about it! Anyway he is keeping me on 2 x 5mg Apixaban. Thanks for all your replies.